Citation NR: 9610364
Decision Date: 04/18/96 Archive Date: 04/25/96
DOCKET NO. 94-18 471 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Seattle,
Washington
THE ISSUES
1. Entitlement to service connection for a left shoulder
disorder.
2. Entitlement to service connection for pyelonephritis.
REPRESENTATION
Appellant represented by: AMVETS
ATTORNEY FOR THE BOARD
C. L. Krasinski, Associate Counsel
INTRODUCTION
The veteran served on active duty from September 1972 to
September 1992.
This matter comes before the Board of Veterans' Appeals
(Board) on appeal from a June 1993 rating decision of the
Seattle, Washington, Department of Veterans Affairs (VA),
Regional Office (RO), denying service connection for a left
shoulder disorder and for pyelonephritis.
REMAND
Review of the veteranís service medical records reveals that
in the July 1984 medical examination report, the examiner
noted that the veteran was diagnosed as having an old left
acromioclavicular separation with resolution of symptoms.
The July 1992 report of medical history indicates that the
veteran reported having a painful or ďtrickĒ shoulder. The
examiner noted that the veteran reported having left shoulder
pain ďonce in awhile.Ē The Board notes that the veteran
underwent a VA Compensation and Pension Examination in
December 1992. The veteranís left shoulder was examined and
the VA examinerís impression was a soft tissue injury of the
left shoulder. An x-ray examination of the veteranís left
shoulder was not ordered.
The veteranís service medical records further reveal that the
veteran was hospitalized for pyelonephritis in December 1972.
He received treatment for urinary tract infections in
service. He was diagnosed as having nonspecific urethritis
in July 1975, September 1976, February 1977, July 1977,
August 1977, and July 1979. In September 1975, the veteran
was diagnosed as having prostatitis. As stated above, the
veteran underwent a VA Compensation and Pension Examination
in December 1992. The VA examiner ordered a urinalysis and
tests of the renal function, but such tests were not
conducted. The Board also notes that the VA examiner
indicated in the December 1992 report that the veteranís
medical records were not available prior to the examination.
The VA has a duty to assist the veteran in the development of
facts pertinent to his claim. 38 U.S.C.A. ß 5107(a) (West
1991); 38 C.F.R. ß 3.103(a) (1995). Fulfillment of the VAís
duty to assist includes providing a complete and thorough
medical examination of the claimed disability that takes into
account the records of the veteranís prior medical treatment,
so that the evaluation of the claimed disability will be a
fully informed one. Schafrath v. Derwinski, 1 Vet.App. 589
(1991). It also includes an examination by a specialist when
deemed appropriate. Littke v. Derwinski, 1 Vet.App. 90
(1990). The Board notes that an x-ray examination of the
veteranís left shoulder is pertinent in this case since the
veteranís service medical records demonstrate that while the
veteran was in service, he complained of left shoulder pain
and he was diagnosed as having an old left acromioclavicular
separation in July 1984. The Board further notes that an
urinalysis and tests of the veteranís renal function are
pertinent, since the veteranís service medical records show
that the veteran was diagnosed as having pyelonephritis and
nonspecific urethritis. Currently, the veteran complains of
sharp pains in his abdomen.
Under the circumstances of this case, the Board is of the
opinion that additional development is required. The case is
REMANDED to the RO for the following:
1. The veteran should be asked to
provide the names and addresses of the
health care providers who have treated
him for his left shoulder disorder and
for genitourinary disorders since his
separation from service in 1992. Any
medical care provider(s) so identified
should be asked to provide copies of the
veteranís medical and treatment records.
The veteran should be asked to sign any
necessary consent forms for the release
of the records.
2. The veteran should be afforded VA
orthopedic and genitourinary examinations
in order to determine the nature and
extent of his left shoulder disorder and
his kidney disorder, to include
pyelonephritis. All indicated studies
should be performed, including a x-ray
examination of the veteranís left
shoulder, renal function tests, and an
urinalysis. All findings and diagnoses
should be reported in detail. The claims
folder should be made available to the
physicians for review before the
examination. The orthopedist and the
urologist and should be asked to
interpret the service medical records and
to express an opinion, in writing, their
respective opinions as to the pathology
of the veteranís left shoulder disorder
and the veteranís abdominal pain. The
examiners should provide a written
assessment as to the significance of
symptoms in service. The rationale for
all conclusions should be provided in
detail, along with citations to the
pertinent evidence upon which such
conclusions are reached. A copy of this
remand should be made available to the
examiner prior to review of the claims
folder.
3. Following completion of the foregoing
examination, the RO must review the
claims folder and ensure that all of the
requested development has been conducted
and completed in full. If any
development is incomplete, appropriate
corrective action is to be taken.
4. After the foregoing has been
completed, the RO should review the
entire claims folder and readjudicate the
veteran's claim for service connection
for a left shoulder disorder and
pyelonephritis.
After the above has been completed, if any benefit sought
remains denied, the veteran and his representative should be
issued a supplemental statement of the case, which includes
the appropriate laws and regulations and adequate reasons and
bases for the RO's decision. The veteran and his
representative, thereafter, should be afforded an opportunity
to respond. The case must then be returned to the Board for
further appellate consideration, if appropriate. The veteran
and his representative need take no further action until
notified by the RO.
The purpose of this remand is to assist the veteran in the
development of his claim and to afford the veteran due
process of law.
REN…E M. PELLETIER
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, ß 6, 108 Stat. 740, ___
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
Under 38 U.S.C.A. ß 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Veterans Appeals. This remand is in the nature of a
preliminary order and does not constitute a decision of the
Board on the merits of your appeal. 38 C.F.R. ß 20.1100(b)
(1995).
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